Gastroenterology Coding Alert

Question: For an outpatient enema (performed for relief of constipation), do I report the procedure and the evaluation and management (E/M)?

Nevada Subscriber

Answer: When the gastroenterologist performs an enema in the office for the removal of impacted feces, that procedure is included in the evaluation and management (E/M) code for a particular date of service. There is no separate procedure code. Typically, that means you’ll select from 99202-99215 (Office or other outpatient visit for the evaluation and management …). Which code you select will depend on the specifics of the encounter as outlined in the physician’s documentation.

Remember that the diagnosis code and any applicable history codes will need to appear with the claim. As for the ICD-10 code, you should report the appropriate constipation code, such as K59.00 (Constipation, unspecified), as the primary diagnosis for this scenario, followed by any additional diagnoses that may exist, such as K50.10 (Crohn’s disease of large intestine without complications).